AMA Honors Katie O. Orrico with Lifetime Achievement Award

amaFrom time to time you will see us promote items on Neurosurgery Blog in order to spotlight some great things which are born out of the many individuals who work on behalf of organized neurosurgery. For our post today we would like to highlight that earlier this week, the American Medical Association awarded Katie O. Orrico, JD, director of the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) Washington Office at the, with the Medical Executive Lifetime Achievement Award. The award honors a medical association executive who has contributed substantially to the goals and ideals of the medical profession.

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Katie O. Orrico, JD

In a press release, AMA President Andrew W. Gurman, MD, stated, “A coalition builder, Katie Orrico has demonstrated time and again throughout her career a tireless commitment to patients and physicians alike.” He added, “Respected by colleagues for her leadership, mentorship and library of knowledge on policy, legislation and government operations, she is a workhorse for a healthier tomorrow.”

We couldn’t agree more and we are honored to work with Katie day in and day out. Please join us in congratulating her on this wonderful accomplishment!

Posted in Faces of Neurosurgery, Health | Tagged , , , , , , , , , , , , , , |

Neurosurgeons Advance Aggressive but Minimally Invasive Brain Tumor Care

tumor-hsShabbar F. Danish, MD, FAANS (left)
Chief, Section of Neurosurgical Oncology, Rutgers University / Rutgers Cancer Institute of New Jersey
New Brunswick, New Jersey

Brian V. Nahed, MD, MSC (middle)
Assistant Professor of Neurosurgery, Massachusetts General Hospital / Harvard Medical School
Boston, MA

Nitesh V. Patel, MD (right)
Neurosurgery Resident, Rutgers University
New Brunswick, New Jersey

More than 70,000 patients will learn that they have a new primary brain tumor this coming year in the United States alone.6 While most of these patients will undergo surgery for removal and diagnosis, there are some for whom surgery is not a good option.5 Historically, treatment interventions for these individuals were more limited. Neurosurgeons frustrated by this limitation have been involved in the development and study of two new FDA-approved treatments. These are thermal therapy systems that sparked a renewed interest in Magnetic Resonance Guided Laser Induced Thermal Therapy (MRgLITT). LITT provides a minimally invasive surgical access coupled with the power of lasers to ablate a tumor from the inside out.

MRgLITT is performed using a navigation system which specifically targets a point in the brain using three-dimensional coordinates called stereotaxis.4 The procedure is simple:

  • A small incision is made in the skin;
  • A small hole in then created in the skull;
  • The laser catheter is placed into the tumor in the brain;
  • Location of the laser is confirmed by live MR thermometry; and
  • Tumor tissue is ablated using real-time MRI.

Imagine, the signals (called pixels) on the MRI images change as the tissue is ablated! This allows real-time tracking to determine the extent of tumor destruction. Temperature limits are set within and around the target to reduce the chance of damage to surrounding healthy tissue.

MRgLITT has been demonstrated to be efficacious in a variety of brain lesions including:

  • Primary brain tumors (gliomas);
  • Tumors that spread to the brain (metastatic lesions); and
  • Radiation necrosis.1
Figure: This is a patient with a recurrent anaplastic ependymoma located below the splenium of the corpus callosum. The patient had undergone multiple craniotomies, fractionated radiation as well as radiosurgery. She underwent placement of a transparietal laser catheter using the Visualase System (Left image). The images on the right represent the follow up images after MRI guided laser therapy.

Figure: This is a patient with a recurrent anaplastic ependymoma located below the splenium of the corpus callosum. The patient had undergone multiple craniotomies, fractionated radiation as well as radiosurgery. She underwent placement of a transparietal laser catheter using the Visualase System (Left image). The images on the right represent the follow up images after MRI guided laser therapy.

For those patients who cannot undergo surgery for any number of reasons, MRgLITT may provide a novel therapeutic option.5 Prior treatment strategies, such as radiation, are limited by dose constraints, and chemotherapy is limited by tumor resistance and getting the agent into the brain (due to blood-brain barrier impermeability).2,3 Real-time monitoring of ablation allows for immediate and direct control of therapy, which can be modified during the intervention in real-time. After surgery, the laser catheter is easily removed, and the skin closed with a stitch. Patients typically spend just 24 hours in the hospital after the procedure before discharge. The treatment is safe with few complications that require the patient return to the hospital (data show less than 6 percent of patients had complications leading to readmission at 30 days after MRgLITT).7

MRgLITT is a promising option that offers hope, but there are still some challenges that require further work:

  • Swelling may get worse after treatment which may cause the patient to develop neurological issues.
  • The natural shape of most tumors is irregular while the laser heat distribution follows a spherical fashion. Modification of the procedure such as stepwise treatment or use of multiple catheters may allow the laser to cover more volume.
  • Fluids in the brain such as ventricles and blood vessels may alter the effect of the laser by creating a heat sink effect and lead to asymmetric heat distribution.

Neurosurgeons will continue to work to overcome these difficulties to bring innovative, minimally invasive new treatment to our many patients who are found to have brain tumors. MRgLITT provides an innovative tool in the neurosurgical armamentarium, especially for previously inaccessible surgical lesions.

References:

  1. Attaar SJ, Patel NV, Hargreaves E, Keller IA, Danish SF: Accuracy of Laser Placement With Frameless Stereotaxy in Magnetic Resonance-Guided Laser-Induced Thermal Therapy. Neurosurgery:14, 2015
  2. Henson JW, Cordon-Cardo C, Posner JB: P-glycoprotein expression in brain tumors. J 14:37-43., 1992
  3. Idbaih A, Omuro A, Ducray F, Hoang-Xuan K: Molecular genetic markers as predictors of response to chemotherapy in gliomas. Curr Opin Oncol. 19:606-611., 2007
  4. Jethwa PR, Barrese JC, Gowda A, Shetty A, Danish SF: Magnetic resonance thermometry-guided laser-induced thermal therapy for intracranial neoplasms: initial experience. 71:133-144; 144-135. doi: 110.1227/NEU.1220b1013e31826101d31826104., 2012
  5. Medvid R, Ruiz A, Komotar RJ, Jagid JR, Ivan ME, Quencer RM, et al: Current Applications of MRI-Guided Laser Interstitial Thermal Therapy in the Treatment of Brain Neoplasms and Epilepsy: A Radiologic and Neurosurgical Overview. AJNR Am J Neuroradiol. 36:1998-2006. doi: 1910.3174/ajnr.A4362. Epub 2015 Jun 1925., 2015
  6. Ostrom QT, Gittleman H, Fulop J, Liu M, Blanda R, Kromer C, et al: CBTRUS Statistical Report: Primary Brain and Central Nervous System Tumors Diagnosed in the United States in 2008-2012. Neuro Oncol. 17:iv1-iv62. doi: 10.1093/neuonc/nov1189. Epub 2015 Oct 1027., 2015
  7. Purvee Patel B, Nitesh V Patel, MD, Shabbar F. Danish, MD: Intracranial Magnetic Resonance Guided Laser Induced Thermal Therapy (MRgLITT): Single Center Experience with the Visualase Thermal Therapy System Journal of Neurosurgery In Production / Press, 2015
Posted in Guest Post, Tumor | Tagged , , , , |

Military Faces: Donald O. Quest, MD

benzilGuest Post from Deborah L. Benzil, MD, FACS, FAANS
Chair, AANS/CNS Communications and Public Relations Committee
Care Mount Medical Group
Columbia University Medical Center
Mt Kisco, New York

Donald O. Quest, MD, FAANS(L), is the consummate neurosurgeon, having reached the pinnacle in surgical technique, as an educator, and in administrative and leadership positions. Medical students, residents and many other neurosurgeons have benefited from his dedication to teaching and mentoring during his long career. Few realize, however, that his distinguished career could easily have been derailed. What a great loss that would have been! Several neurosurgeons served in Vietnam as physicians, and we have previously highlighted the experience of Patrick J. Kelly, MD, FAANS(L) and Stan Pelofsky, MD, FAANS(L). Don Quest’s Vietnam encounter came in a very different way and thus had a different impact. Recently, Dr. Quest agreed to discuss his Vietnam combat experience and to share it with others for the Military Faces feature of the Neurosurgery Blog.

Donald O. Quest, MD

Donald O. Quest, MD

Growing up a Midwesterner, Dr. Quest had never seen an ocean, but he had the great fortune of gaining a coveted Navy scholarship to cover the entire cost of his undergraduate education. After a summer seasick on a destroyer, and one spent with the Marines, he made the decision to become a Navy pilot. Following undergraduate graduation at the University of Illinois, where he majored in mathematics, he attended flight training and rapidly moved through all the steps of aircraft carrier qualification. As he related in his AANS Presidential address in 2007, despite his exposure to World War II memories as a child, “when joining the military in times of peace one doesn’t think of having to fight-naiveté or wishful thinking.” Upon receiving his Navy wings — mastering flight of the Douglas Skyraider as a single-engine fighter — he was assigned to Attack Squadron 115 in the Pacific. It was the early 1960s. His aircraft carrier was the new USS Kitty Hawk, and while there were stops in exotic ports such as Hong Kong, there was also the conflict in Vietnam.

The year was 1964 when his squadron became engaged in the Vietnam Conflict. During the ensuing years, he flew 31 successful combat missions, with the purpose of interrupting supply routes, close air support in the South and covering during rescue operations in the North. These were the same types of flights familiar to many Americans as those flown by Senator John McCain (which led to his long years as a POW).  Dr. Quest still attends Veteran conventions but is glad that many of the more difficult memories of those years have faded. With clear visceral recall, however, he related the fear of performing a treacherous landing on the ship at night in the rain, when the margin for error was even smaller than usual. Even more frightening was being fired on at night when the black sky provided a stark contrast to the many flares, tracers and missiles illuminated at close range. While he has traveled extensively and been to other parts of Asia, he has no desire to return to Vietnam — the memories and the losses are still too great.

His experience in Vietnam has shaped the remainder of his life and greatly influenced many of his choices. In his inimitable way, Dr. Quest turned tragedy to good, and neurosurgery is thankful for this along with many patients and their families whose lives he has touched. Upon return, he applied to just two medical schools and was accepted and attended Columbia University College of Physicians and Surgeons. While he started medical school with no chosen specialty, he recognizes that having achieved the pinnacle position of carrier pilot probably influenced his ultimate choice of neurosurgery (then considered an elite subspecialty). Early exposure to neuroscience giants including J. Lawrence Pool, MD, and H. Houston Merritt, MD, were other important factors.

In retrospect, Dr. Quest saw many parallels of flight training and neurosurgical training and poignantly devoted his AANS Presidential address entirely to this subject. Beyond this, he also notes several other valuable and impactful lessons from his Navy years. The importance of teamwork has continuously been a driving force, always recruiting great people. The result has been departments and boards known for their depth and breadth. Working on a Quest team, one always feels respected and that your ideas are heard. This is a rare and remarkable trait. Further, he stresses the need to develop skills and knowledge to a top degree as well as achieving the capacity to intuitively and creatively get out of trouble should the need arise.

jazzToday, Dr. Quest remains dedicated to education and mentoring, primarily through his role as Assistant Dean of Student Affairs at Columbia College of Physicians and Surgeons. He also remains an active member of the neurosurgery faculty as a professor. After 75 years, he is spry, cuts a sharp figure, can play exuberant jazz sets on the trombone and displays wisdom and philosophy as befits him. Dr. Quest did not choose to spend years in active combat, but that is what life dealt him. Remembering those years is clearly still painful, and he is acutely aware of the difference between the hero reception of the WWII pilots compared with opposite received by the veterans of the Vietnam Conflict. Reflecting on this recently, he poignantly stated, “when those making a decision about going to war haven’t ever experienced combat, there is too much potential for catastrophe.” He further rued the wanton attacks on the character of Veterans such as Senator McCain.

For Don Quest, the words of Shakespeare’s Henry V capture much of what is essential in battle and in neurosurgery (and some might add in all of life):  mission, camaraderie and loyalty. All of neurosurgery honors Dr. Don Quest for his many contributions to the military and subsequently neurosurgery with these fitting words:

hs

Donald O. Quest, MD

This story shall the good man teach his son
And Crispin Crispian shall ne’er go by,
From this day to the ending of the world
But we in it shall be remembered
We few, we happy few, we band of brothers;
For he to-day that shed his blood with me
Shall be my brother, be he ne’er so vile
This day shall gentle his condition:
And gentlemen in England now a-bed
Shall think themselves accursed they were not here
And hold their manhoods cheap whiles any speaks
That fought with us upon Saint Crispin’s day.

 

Posted in Faces of Neurosurgery, Guest Post, Military Faces of Neurosurgery | Tagged , , , , , , , , , , , , , |